Wrinkles
Called rhytids
Dynamic due to repeat muscle movement
Static: due to loss of skin elasticity (chemical peels and lasers)
Glogau:
Level of photoaging and classifies wrinkles
Fitzpatrick scale
Eval of skin response to UV
Rhino Evaluation
Can evaluate deviation, wideness, tip shaped, dorm shape
Can do bottles test to address the internal nasal valve,
External nasal valve is watching patient breathe forcefully.
Dedo neck classification
Cervicomandibular angle
Open vs end-nasal technique
Open has prolonged tip swelling but greater access. Approaches is dorsal, Killian incision, or semi transfixion approach.
Endonsaal is shorter but limited access especially if grafting
Spreader grafts, strut grafts, and batten grafts, last for the lateral crura.
Shield grafts for tip definition
Transdomal suturing to narrow and support tip.
Post Op Rhino
Edema takes 1 year to resolve, should be on abx for the duration of the intranasal packing, nasal precautions for 2 weeks.
Pollybeak deformaity
fullness of the nasal supra trip relative to nose, can be cartilaginous or soft tissue cause by inadequate/excessive dorsal septum removal
Open roof deformity
flat dorm after a large hump reduction
Inverted L
collapse of upper lateral cartilages and nasal bones can be seen through
Pearls:
Need 8 mm of lower lateral cartilage
Anterior septal angle should be used for hump reduction
2-4 mm of columella shown from profile.
Rhytidectomy
Face lift through manipulation of SMAS
Physical exam for facelift
neck laxity, howling, mesolabial/nasolabial folds, platysmal dehiscience, howling, nasolabial folds, marionette lines, skeletal profile.
There are superficial and deep plane face lifts
SMAS plication is folded on itself, imbrication is incised and overlapped,
Post Op
Facelift dressing for first 48 hours than nightly for 1 week, 24 hours post for evaluation and ice.
No alcohol (7 days) and smoking , sunblock abx and peroxide to clean.
Necrosis usually post auricular, clean and maintain moisture and pos nitropaste and HBO.
Scars
Steroids like triamcinolone 3mg every 6 weeks for 3 month, Laser resurfacing .
Greater auricular nerve
comes back in 6 months, typically is paresthesia over lower lobe and SCM
Hyperpigmentation
usually resolves in 6 months, but 4% hydroquinone is effective
Platysmaplasty
rejuvenates the submittal area of the neck, done in combo with a facelift in older than 40.
Superficial fat layer can be removed via liposuction or deoxycholic acid injection called kybella.
Complication of neck lipo/ pasty
exposure of platysmas bands, cobra neck deformity. submandibular gland ptosis,
Toxic of plain lido is 4.5mg/kg for cal, with epi is 7mg/kg
Toxicity?
Circumoral numbness, sleepiness, confusion, seizures, leads to Brady and hypotension.
Treat is airway, fluids, benzes for seizures, vasopressors, and intralipid infusion 20%
Bleph Eval
if they have dry eyes or ocular surgeries,
Female brow above orbital rim, males at rim
Make sure not due to brow toss
Margin reflex distance from central cornea to eyelid margin typically is 4mm
Schrimer test
Place paper in lower fornix, should be 10mm of wetness, dont do bleh if under due to possible lagophthalmos.
excess eyelid skin called
Dermatochalasis: indication for upper lid blepharoplasty
typically around 8mm from edge of eyelid, can do a skin test to evaluate how much excess, safe to leave ~20
Can see lacrimal grand prolapse and can be suspended in orbital rim with mattress sutures.
Lower lid bleph
MRD here is 5.5, can generally pull on eyelid and should snap back to position.
